Provider Manual

Chapter 21: Outpatient Diagnostic Imaging Privileging

CHAPTER OVERVIEW

Practitioners other than radiologists may, under some circumstances, perform in-office imaging as part of their diagnostic and treatment plans. Outpatient diagnostic imaging privileging protocol promotes the appropriate use of diagnostic imaging by practitioners in an office setting. The protocol designates which imaging procedures are reimbursed (subject to the member's benefit plan) according to practitioner specialty. It also describes the minimum practitioner accreditation and certification requirements. 

Our outpatient diagnostic imaging privileging protocols are based on a careful review of the literature and standards of the National Board of Echocardiography (NBE), Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR), and American Board of Radiology (ABR).

 

Practitioners must meet the minimum certification requirements for their specialty. These protocols assume board certification (by an American Board of Medical Specialties recognized board) in the listed adult or pediatric provider specialties.

Claims are denied with no liability to the member when outpatient imaging procedures are performed outside the practitioner's specialty, or when the practitioner fails to maintain the minimum certification requirements or does not obtain preauthorization when required.
 

The imaging privileging protocols for HIP/HIPIC-underwritten benefits plans are contained in the HIP Outpatient Diagnostic Imaging Self-Referral Payment Policy chart. This payment policy excludes:

  • Services rendered in Putnam and Ulster Counties.
  • Members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP). Check the member's ID card or eligibility information on emblemhealth.com/providers to determine the entity responsible for managing a member's care. Practitioners must contact the applicable organization for privileging protocols.

The imaging privileging protocols for GHI PPO City of New York plans are contained in the GHI PPO City of New York Outpatient Diagnostic Imaging Self-Referral Payment Policy chart.
 

The imaging privileging protocols for other members with GHI-underwritten benefit plans and all-numeric member IDs are contained in the Radiology Privileging by Specialty chart.

EmblemHealth reimburses cardiologists for approved echocardiography studies (CPT codes 93303, 93304, 93306, 93307, 93308, 93350 and 93351) and nuclear studies (CPT codes 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483 and 78494), but only if they are performed at accredited locations. Pre-authorization rules apply where applicable.

 

Accreditation for echocardiography studies requires both:

  1. Cardiology board certification of the physician by the American Board of Internal Medicine (ABIM), American Osteopathic Board of Internal Medicine (AOBIM), or National Board of Echocardiography (NBE) and
  2. Services rendered in laboratories accredited in transthoracic echocardiography by the Intersocietal Accreditation Commission (IAC- Echocardiography).
Accreditation for nuclear studies requires both:
  1. Certification of the physician by the American Board of Radiology (ABR), American Board of Nuclear Medicine (ABNM) or Certification Board of Nuclear Cardiology (CBNC) and
  2. Services rendered in laboratories accredited for Nuclear/PET by the Intersocietal Accreditation Commission (IAC-Nuclear/PET) or American College of Radiology (ACR-Nuclear Medicine.

Accreditation for PET studies requires:

  1. Certification of the physician by the American Board of Radiology (ABR) or American Board of Nuclear Medicine (ABNM) or American Board of Internal Medicine in cardiology, and
  2. Certification of the physician by Certification Board of Nuclear Cardiology (CBNC), and
  3. Services rendered in laboratories accredited for PET by the Intersocietal Accreditation Commission (IAC-Nuclear/PET w/cardiac imaging or American College of Radiology (ACR in Pet).

Participating practitioners are reviewed for active accreditation. For echocardiography services, the review appears in the national databases of IAC-Echocardiography. For nuclear medicine/nuclear cardiology services, the review appears in the national database of ACR and IAC-Nuclear/PET. For PET services, the review appears in the national database of IAC-Nuclear/Pet and ACR-PET.

All other specialties must email their certification(s) directly to provideraccreditations@evicore.com. For more information about accreditation status or certificate submissions, email provideraccreditations@evicore.com or call 1-800-918-8924, ext. 27901.

For information on accreditation requirements and instructions for submitting an application for accreditation, refer to the websites of the accrediting organizations below: